Viral Hepatitis: slow killer being targeted for elimination

Approximately 325 million people worldwide are infected with deadly viruses that are slowly sabotaging their livers. Most of them don’t have any symptoms yet. Many don’t know they are infected. But in five, ten or maybe fifteen years they are likely to die from liver cancer or cirrhosis of the liver.

Ben Duncan

Senior Adviser

In 2016 the World Health Organization launched a global strategy to improve prevention and control all forms of viral hepatitis, and to eliminate Hepatitis B and C by 2030. On World Hepatitis Day, 28 July, we ask: can Hepatitis B and C be eliminated? And what does this mean for Europe?

Viral hepatitis is a group of diseases rather than a single infection. There are five viruses that can cause it: Hepatitis A, B, C, D and E. The A and E viruses are generally transmitted by contaminated food or water. Hepatitis B and C are generally blood-borne or sexually transmitted infections, while hepatitis D is a co-infection that only seems to infect people who already have hepatitis B.

For many years hepatitis viruses, and particularly the food borne viruses hepatitis A and hepatitis E, have cause outbreaks where large number of people become ill in rapid succession. But in recent decades, doctors have come to realise that “silent epidemics” across the world are the biggest threat posed by viral hepatitis. Research began to reveal the role these viruses play in causing millions of deaths each year from liver cancer and cirrhosis of the liver. People could be infected with viral hepatitis without developing symptoms: they only found out about their infection once it had destroyed their liver. Most worryingly of all, hundreds of millions of people around the world who thought they were healthy were carrying this time bomb in their livers.

As stated already, the World Health Organization (WHO) estimates 325million people worldwide have chronic – mostly symptomless – viral hepatitis infections: some 257 million people were living with hepatitis B infection, and 71 million people were living with hepatitis C. WHO estimates that in 2015 alone, viral hepatitis caused 1.34 million deaths in 2015. To put this in context, this is comparable to the number of deaths worldwide caused each year by tuberculosis (TB). And it is more than the number of deaths from HIV in 2015

The good news is that hepatitis B can be prevented by a simple, safe and cheap vaccine. This vaccine has been used for many years in the world’s richer countries. Global action led by WHO has meant this vaccine is increasingly being used in poorer countries as well. As a result, the proportion of children under 5 infected with hepatitis B has declined dramatically. However, WHO warns that 1.75 million adults were newly infected with HCV in 2015. This was largely due to injecting drug use and unsafe injections (e.g. re-using needles) in health care settings in poorer countries.

In 2014 a new medicine that could cure chronic hepatitis C infection started to be sold in the US and Europe. This was Sovaldi produced by Gilead Pharmaceuticals. A number of similar treatments developed by other pharmaceutical companies were approved in the years that followed. The challenge for health authorities, though, was that these expensive new drugs arrived at a time when health budgets across the globe are under huge financial pressure. In 2015, 1.1 million people worldwide received treatment for their hepatitis C. This sounds impressive until you realise it is just 7% of people identified as having hepatitis C. In other words, fewer than 1 in 10 people with hepatitis C received the life-saving (and expensive) medicine they needed.

WHO is confident it is on track to meet its 2030 targets of 90% of people with HBV and HCV infections being tested, and 80% of eligible patients receiving treatment. WHO’s 2016 Global strategy on viral hepatitis , the World Hepatitis Alliance’s “Show Your Face” campaign and the World Hepatitis Summit to be held in Sao Paulo, Brazil on 1 to 3 November this year, show the fight to eliminate hepatitis B and C has got political momentum. But this will need to be sustained for many years – and turned into cash for hepatitis C treatment – if the goals are to be reached.

What does this all mean for Europe?

The vast majority of viral hepatitis infections and deaths occur in the developing world. 28 low and middle-income countries account of 70% of the worldwide burden of chronic hepatitis infection, with the top 11 high burden countries – Brazil, China, Egypt, India, Indonesia, Mongolia, Myanmar, Nigeria, Pakistan, Uganda, Vietnam – accounting for around 50% of the total global burden. Nonetheless, millions of Europeans are also affected by these viruses.

An evidence review published by the European Centre for Disease Prevention and Control (ECDC) in 2016 estimated that more than 10 million people in the EU and EEA countries may have chronic hepatitis B or hepatitis C. In 2015, nearly 35,000 new cases of hepatitis C and over 24,000 new cases of hepatitis B were diagnosed in these countries.

Further, in 2017, ECDC and national health authorities in Europe have highlighted an upsurge in hepatitis A infections in the EU. This is driven, to a significant degree, by sexual transmission of hepatitis A between men having sex with men. See ECDC website for more details on this. Meanwhile, earlier in July, ECDC published data from 20 European countries on hepatitis E infection. This showed the number of cases in Europe increasing sharply: from just 514 cases in 2005 to 5,617 cases in 2015. This a ten-fold increase. In total, 28 deaths associated with hepatitis E infection were reported from five European countries between 2005 and 2015.

“When we talk about the target of eliminating viral hepatitis as a public health issue by 2030, we should also keep hepatitis E in mind” says Prof Mike Catchpole, ECDC’s Chief Scientist.